C 2005), pp. 611–625 Cognitive Therapy and Research, Vol. 29, No. 5, October 2005 ( DOI: 10.1007/s10608-005-5774-1
Tracking Readiness and Motivation for Change in Individuals with Eating Disorders Over the Course of Treatment Josie Geller,1,2,4 Shannon L. Zaitsoff,2,3 and Suja Srikameswaran1,2
Ambivalence about recovery is a key aspect of the symptom presentation of individuals with eating disorders and increased attention has focused on understanding readiness for change in this group. This research examined shifts in global and symptom-specific readiness and motivation for change during residential eating disorders treatment. Forty-two participants completed the Readiness and Motivation Interview (RMI) prior to treatment, at week 7, and following the 12–15 week program. Demographic and symptom severity measures were completed at pre and at post. Overall, increases in readiness to change behavioral symptoms occurred prior to increases in readiness to change cognitive symptoms. Shifts in locus of control for change were less pronounced during treatment, and occurred only for the cognitive symptom domain. Subgroup analyses revealed that relative to the other eating disorder diagnostic groups (bulimia nervosa and eating disorder not otherwise specified), readiness for change in individuals with anorexia nervosa shifted less over the course of treatment. KEY WORDS: readiness and motivation; eating disorders; cognitive change; behavioral change.
Eating disorder clinicians are commonly faced with the task of encouraging change in individuals who do not experience their symptoms as a problem. Conflicts that emerge from these differing client and clinician agendas may be responsible for the oft-cited problems of treatment refusal and dropout (e.g., Pike, 1998). In order to address these treatment difficulties, increased attention has focused on understanding ambivalence about recovery in this group. For instance, recent research studies have identified barriers to recovery that may be unique to the eating disorders (e.g., Cockell, Geller, & Linden, 2003; Serpell, Treasure, Teasdale, & Sullivan, 1999; Vitousek, DeViva, Slay, & Manke, 1995) and a number of new readiness for 1 Department
of Psychiatry, University of British Columbia, Vancouver, BC, Canada. Disorders Program, St. Paul’s Hospital, Vancouver, BC, Canada. 3 Department of Psychology, University of Windsor, Windsor, Ontario, Canada. 4 Correspondence should be directed to Josie Geller, Eating Disorders Program, St. Paul’s Hospital, 1081 Burrard St., Vancouver, BC, Canada. V6Z1Y6; e-mail:
[email protected]. 2 Eating
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change assessment tools have been developed. These have been either adapted from the substance use literature (Stanton, Rebert, & Zinn, 1986; Blake, Turnbull, & Treasure, 1997; Ward, Troop, Todd, & Treasure, 1996), or newly developed for this group (e.g., Cockell, Geller, & Linden 2001; Geller & Drab, 1999; Rieger et al., 2000). The transtheoretical model of change provides a framework for conceptualizing readiness for change in treatment-resistant individuals (Prochaska, 1979; Prochaska, DiClemente, & Norcross, 1992). According to this model, individuals can be categorized into one of five stages: precontemplation (being unaware of, or unwilling to change symptoms), contemplation (seriously thinking about change), preparation (having the intention of changing soon) action (actively modifying behavior and experiences in order to overcome a problem) and maintenance (working to prevent relapse). Several measures have been developed based upon this model, including the Stages of Change Questionnaire (SCQ; McConnaughy et al., 1983), which has been used to assess stage of change in a number of populations. Using the SCQ, individuals are assigned a stage of change score based upon conceptualization of the eating disorder as a single problem. In contrast, the Readiness and Motivation Interview (RMI) is a semi-structured interview measure of readiness for change in the eating disorders (Geller, Cockell, & Drab, 2001; Geller & Drab, 1999) in which stage of change is assessed across different eating disorder symptoms. That is, the RMI provides precontemplation, contemplation, and action/maintenance scores for each of four symptom domains: restriction, cognitive, bingeing, and compensatory behaviors. The RMI also establishes the extent to which change is occurring for internal vs. external reasons. The stance of the assessor in the RMI is a central feature of the interview. That is, consistent with applications of motivational interviewing to the eating disorders (i.e., Geller, Williams, & Srikameswaran, 2001), RMI assessors express acceptance, curiosity and interest in any ambivalence about change the client may be experiencing. This stance is thought to be conducive to a more open, honest discussion about readiness for change. Previous research using the RMI has shown that readiness and motivation in the eating disorders differs across symptom domains. For instance, in a heterogeneous sample of individuals referred for eating disorders treatment, overall readiness to change the behavioral domains of restriction and compensatory strategies was lower than readiness to change cognitive features, such as fear of weight gain and overvalued ideas about shape and weight (Geller, Cockell, & Drab, 2001). In addition, unlike the SCQ, which has not been shown to consistently predict clinical outcomes in the eating disorders (Geller, Cockell, & Drab, 2001; Pike, 1998; Treasure et al., 1999), the RMI has been used with greater success. That is, RMI scores predict enrolment and dropout from intensive treatment, symptom change post-treatment, and maintenance of change at 6-month follow-up (Geller et al., 2001; Geller, Whisenhunt, & Drab, 2002). Of the four symptom domains, readiness to change restriction over eating (i.e., dietary restraint, weight control behavior) appears to be most closely linked with clinical outcome (Geller et al., 2002). Together, research to date on readiness and motivation for change in the eating disorders suggests that comprehensive assessment strategies such as the RMI are needed to fully understand an individual’s experience.
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The temporal relationship between cognitive and behavioral change during recovery has been the focus of considerable conceptual and theoretical debate in the treatment literature across a number of disorders (e.g., Beck & Hollon, 1993; Cooper & Fairburn, 1993; Fairburn, Peveler, Jones, Hope, & Doll, 1993; Salkovskis, 1991). That is, the extent to which cognitive shifts precede, follow, or occur concurrently with behavioral change is of theoretical and clinical interest. Some work in the anxiety disorders suggests that behavioral change typically precedes cognitive change and is essential to good outcome (Rachman, 1990). Other studies in depression suggest that symptom improvements (“sudden gains”) which lead to long term positive outcome are preceded by cognitive shifts (Tang, Luborski, & Andrusyna, 2002; Tang & DeRubeis, 1999). Across diagnoses, the optimal order of behavioral and cognitive shifts in these populations is unclear. In the eating disorders, little is known about when behavioral change is best introduced into treatment protocols, and making this decision can be especially challenging for care providers given the high levels of ambivalence about change expressed in this group. As a result, understanding shifts in readiness for change, as opposed to shifts in actual cognitive and behavioral change, is critical in developing optimal models of treatment in the eating disorders. The Discovery/Vista Day Program is a 12–15 week intensive treatment for adults with severe eating disorders, in which participation requires active engagement in both cognitive and behavioral change throughout treatment. Admission to Discovery/Vista requires that individuals who are underweight be willing to gain weight at the rate of 0.5–1.0 Kg per week until reaching maintenance. Bingeing and purging are not permitted in the therapeutic environments. Individuals who are unable to meet the program’s expectations of change are required to take a 1-week step out and/or leave program. In order to ensure that clients have the best chance of successfully completing program, Discovery/Vista selects participants on the basis of their expressed readiness for change. Previous research has shown that clients who enroll in Discovery/Vista have higher RMI action and lower RMI precontemplation scores than individuals who do not enroll in program (Geller, Cockell, & Drab, 2001). Participation in Discovery/Vista program involves weekly individual psychotherapy, and cognitive behavioral, assertiveness training, and body image therapy groups. The program makes use of interpersonal, cognitive-behavioral, and dynamic therapeutic approaches. The purpose of this research was to use the RMI to describe global and symptom-specific readiness for change prior to, mid-way through, and following treatment in the Discovery/Vista program. Given the requirements and structure of the program, it was expected that RMI action scores would increase during program. However, it was not known whether cognitive and behavioral shifts would occur simultaneously, or whether changes in internality (i.e., the extent to which individuals were making changes for themselves vs. for others), could be expected. As such, exploratory analyses were conducted to examine changes in readiness and motivation and in internality across behavioral and cognitive symptom domains. Finally, exploratory analyses were conducted to examine whether shifts in readiness differ according to diagnostic status.
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METHOD Participants Fifty-three consecutive admissions to the Discovery Program were invited to participate in this research. Diagnoses were made by a clinical psychologist and four clinical Psychology graduate students, using the diagnostic questions from the Eating Disorders Exam (EDE; Cooper & Fairburn, 1987). A diagnosis of anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified was made when all of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (American Psychiatric Association, 1994) criteria were satisfied for a period of 3 months prior to being assessed. Independent diagnoses were made by the program’s medical internist and by the research assessor. Any discrepancies or ambiguous cases were discussed with the first author in regular supervision meetings in which the final decision regarding diagnosis was made. Of those included in the study, 17 were rated as anorexia nervosa restricting (AN-R) subtype, 4 as anorexia nervosa binge/purge (AN-BP) subtype, 7 as bulimia nervosa (BN), and 14 as eating disorder not otherwise specified (EDNOS). Of those diagnosed with EDNOS, none met the weight criterion for AN, and 12 of the 14 used at least one form of compensatory strategy (vomiting, diuretics, laxatives, or excessive exercise). The mean duration of eating disorder was 12.19 years (SD = 9.1). Mean BMI for individuals with anorexia nervosa (n = 21) was 16.79 (SD = 1.07) and 22.39 (SD = 5.71) for the remainder of the sample (n = 21). The sample was comprised of 41 women and 1 man. The average age of participants in this sample was 26.62 years (SD = 9.77) and socioeconomic status (SES) was 2.06 (SD = 0.98) on the Hollingshead Index (Hollingshead, 1979), indicating upper middle class. Measures Demographic Information Sheet. Participants provided their age, height, weight, age of onset of their eating disorder, and the highest education and occupation of their parents, or themselves, depending upon their living arrangement. The Hollingshead Index (1979) was used to calculate SES using the latter two variables. Readiness and Motivation Interview (RMI; Geller, Cockell, & Drab, 2001; Geller & Drab, 1999). The RMI is a semi-structured interview that elicits information on individuals’ readiness and motivation to change their eating disorder symptoms. RMI questions are used in conjunction with each of the diagnostic questions from the EDE, so that both diagnostic information and motivational status is obtained for each symptom. However, unlike the EDE, which draws upon participants’ experiences with their symptoms over the previous 3 months, RMI questions address readiness and motivation over the past 2 weeks. All of the diagnostic items in the EDE, and one additional item (restraint over eating), are included in the RMI. The EDE questions assess cognitive symptoms (fear of weight gain, feelings of fatness, importance of shape, importance of weight), restriction (restraint over eating, dietary restriction outside bulimic episodes), bingeing (objective bulimic episodes), and compensatory strategies (self-induced vomiting, laxative misuse, diuretic
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misuse, and exercise). These four symptom categories (cognitive, restriction, bingeing, and compensatory behaviors) make up the subscales of the RMI (Geller & Drab, 1999). For each symptom, the RMI assesses readiness and motivation status, and the extent to which change, when occurring, is for internal vs. external reasons. The RMI provides motivational stage scores (precontemplation, contemplation, action/maintenance, and internality) for each of four symptom domains (restriction, cognitive symptoms, bingeing, and compensatory behaviors), as well as total precontemplation, contemplation, action/maintenance, and internality scores. RMI stage scores can range from 0 to 100% (estimated to the nearest 10% increment), with the three ratings (precontemplation, contemplation, and action) adding up to 100%. The internality rating captures the locus of control, in percent, for each symptom in which action is occurring. A rating of 0% corresponds to complete externality, or all change efforts aimed at meeting other people’s desires for improvement, and a rating of 100% corresponds to complete internality, or all change efforts are for the self. Total scores are calculated as the mean of readiness ratings across all symptoms. The RMI has demonstrated good inter-rater reliability, ranging from 95.6 to 97.4% agreement for each stage of change, and internal consistency, ranging from .63 to .84 (Geller et al., 2001). With regard to convergent validity, RMI scores have been shown to correlate in the expected directions with scores on the Stages of Change Questionnaire (McConnaughy et al., 1983) and on a questionnaire measure of change activities, the Processes of Change Questionnaire (Ward et al., 1996). Previous research has also shown the RMI to predict both analogue and clinical measures of outcome, including anticipated difficulty of recovery activities, completion of recovery activities, and the decision to enroll in, and dropout from intensive treatment (Geller et al., 2001). Eating Disorders Inventory-2 (EDI-2; Garner, 1991). This is a 91-item selfreport questionnaire designed to measure attitudes, personality features, and eating disorder symptoms thought to be relevant to anorexia nervosa and bulimia nervosa. Subjects are asked to rate each item on a 6-point scale ranging from “never” to “always.” In this research, the Drive for Thinness (DT), Bulimia (B), and Body Dissatisfaction (BD) subscales were used. Extensive psychometric support for this instrument is available (Garner, 1991). Brief Symptom Inventory (BSI; Derogatis, 1993). The BSI is a 53-item inventory of psychiatric symptoms. Respondents indicate the extent to which they are distressed by various problems on 5-point scales. The BSI yields nine primary symptom scale scores and three global indices of distress, including the Global Severity Index (GSI), or the average distress experienced across all symptom domains. For the purposes of this study, the Anxiety, Depression, and Obsessive Compulsive subscales, common comorbid psychiatric conditions, as well as the GSI, were used. The psychometric properties of the BSI are well established, and norms are available for subscale and global scores (Derogatis, 1993). Shape- and Weight- Based Self-Esteem Inventory (SAWBS; Geller, Johnston, & Madsen, 1997; Geller et al., 1998). The SAWBS Inventory assesses the extent to which feelings of self-worth are based upon shape and weight. In the SAWBS
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Inventory, individuals select and rank order from a list of attributes those that are important to their feelings of self-esteem. Participants then divide a circle into pieces, such that the size of each piece reflects the importance of each attribute. The SAWBS score is the angle, in degrees, of the shape and weight piece. The SAWBS Inventory has been shown to have good test-retest reliability and concurrent and discriminant validity (Geller et al., 1997). Procedure Initial contact with participants was made by the research assistant no more than 4 weeks prior to their start date in the Discovery/Vista program. In the initial research assessment, participants received a verbal and written description of the study, and provided written informed consent. In an effort to minimize the tendency to respond in a socially desirable way, participants were assured that information shared in this and subsequent research assessments would not be communicated with members of the clinic team, and would not affect treatment recommendations or care in any way. It was also emphasized that the focus of the research was on understanding ambivalence about recovery, that it was anticipated that participants might have a range of feelings about change, and that understanding these feelings was the focus of the research. This information was reiterated prior to each research assessment. At the initial assessment, following review of consent, participants completed the RMI, SAWBS, EDI, and BSI. Mid-way through the treatment program (approximately week 7), participants completed the RMI with the EDE symptom questions reviewing only the previous 4 weeks. At post-treatment, participants completed the mid version of the RMI, the SAWBS, EDI, and BSI. Participants were weighed at all three time points. RESULTS Description of Pre-Post Changes in Sample Eleven participants (20.8%) did not complete the treatment program because they were unable or unwilling to meet program requirements. As shown in previous research on the relationship between readiness scores and clinical outcomes, this group of treatment dropouts had higher precontemplation scores at baseline (Geller, Cockell, & Drab, 2001) than did those who completed treatment. Overall, individuals who completed the Discovery/Vista program showed improvements across all eating disorder and psychiatric symptom domains. No participants who completed program met DSM-IV criteria for anorexia nervosa or for bulimia nervosa at post. This is not surprising given that for the duration of treatment, behavioral symptoms were restricted by program guidelines (e.g., dietary restraint, binge eating, and compensatory strategies were not allowed on the treatment premises, and exercise was limited). However, the majority of women continued to report varying levels of cognitive symptoms. That is, using EDE diagnostic criteria for
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Table I. Description of Sample at Pre and Post Treatmenta
BMI AN Group EDNOS & BN Group EDI Drive for Thinness Body Dissatisfaction Bulimia SAWBS (degrees) BSI (%)b Global severity Depression Anxiety Obsessive Compulsive
PRE M (SD)
POST M (SD)
16.8 (1.2) 21.1 (2.3)
19.9 (.8) 22.7 (3.3)
15.1 (5.1) 19.1 (6.9) 5.4 (6.2) 148.0 (77.0)
8.8 (7.0) 14.9 (8.3) 1.2 (2.6) 80.6 (51.3)
79 66 69 75
46 35 46 50
Note. BMI: Body Mass Index, EDI: Eating Disorders Inventory, SAWBS: Shape and weight-based self-esteem, BSI: Brief Symptom Inventory. a All pre-post differences are significantly different (all p’s < .01). bBSI percentile scores are with reference to female outpatient norms.
months 1, 2, and 3, 12 participants were above the clinical cutoff score for fear of weight gain, 15 for feelings of fatness, and 24 for importance of shape or weight. With regard to weight gain, none of the women had a Body Mass Index below 17.5 (the cut off for AN) and 32 of the women had a normal BMI of 20 or more. A repeated measures Multivariate Analyses of Variance (MANOVA) comparing pre and post EDI Drive for Thinness (DT), Bulimia (B), and Body Dissatisfaction (BD) scores was significant, F (3, 33) = 18.35, p < .001, (η2 = .63). Univariate analyses indicated improvements for all three subscales; F (1, 35) = 39.40, p < .001(η2 = .53), F (1, 35) = 19.38, p < .001(η2 = .36), and F (1, 35) = 10.61, p < .01(η2 = .23), for DT, B, and BD, respectively. In addition, the extent to which self-esteem was based upon shape and weight (SAWBS scores) decreased, t(25) = 4.08, p < .001, (η2 = .40).5 BMI increased for the subgroup of individuals with an initial diagnosis of anorexia nervosa t(21) = −16.15, p < .001, (η2 = .93), as well as for those who had an initial diagnosis of BN or EDNOS t(20) = −5.75, p
